P - 77419REQUEST FOR ELECTRICAL INSPECTION
/� % Minnesota Board of Electricity ��
1��`t 1- 5 3 3 1821 University Avenue Suite S-128, Saint Paul, Minnesota 55104 -
(651) 642-0800 T'fY/MRS 1-800-627-3529 -
www.electricity.state.mn.us
Identify the work covered by this request: � ��� Y n�� �� � � S ,
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❑ NEW ❑ REMODEL pADDITION REPAIR
GENERAL FEES Outdoor ' htln Standarcl �$t
SERVICES / POWER SUPPLIES Tra�c Si nal Standard �$5
0 to 400 Am re �$25 Su lemental Fee (� $20
401 to 800 Am re �$50 Transformers u to 10 KVA �$10
Above 800 Am re�$75 Transfortners over 10 KVA �$20
CIRCUITS / FEEDERS Transformer I Power Su for Si ns / Outline Li htin �$5
0 to 200 A re �$5 ONE 8 TWO FAMILY DWELLINGS, EACH UNIT
Above 200 Am ere (� $10 Includes the Service and/or Power Supply up to 500 Amperes, All
ALARM, COMMUNICATION, REMOTE CONTROL, SIGNALING Circuits and Two Inspection Trips Each Dwelli Unit �$80
CIRCUITS, CIRCUITS OF LESS THAN 50 VOLTS Additional In ion Tri s�$20
Each Svstem Device or aratus �$.50 in�a�f��afNO Foa
JDITIONS TO THE GENERAL FEES
3 to 12 Unfts �$50 Per Unft
Each Additional Unft � $25
OTHER ADDITIONAL
Lighting Retrofit � $25 per Fixture
Center Pivot Irrigation Boom � $40
Manuhactured Home Park Lots � $25
Recreational Vehide Park Sites (� �5
I herebv certiNN that I
Fee �
total fee is
installatlon described herein on the
S ial Ins ion �$30 r Hour �"'�a" ,,,��
S ial In ' n�$.31 r Mile '�—�` Z� �
_ THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 MONTHS
FOR OFFICE USE ONLY
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Req�est Dat� � Rough-in Inspection Required? ❑ Yes �lo Inspection Other Than Rough-In: eady Now ❑ Will Call '�
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( � J You must call the inspector when ready! � Date Ready:
I certify that I am the ICENSED CONTRACTOR ❑ COMPANY ❑ OWNER and hereby request inspection of ihe electrical work at:
Job Address (Street, x, or Route No.) City �/ � Zip Code
2� Co �,? c� �'� 3 Z
Section Township a Fire No. CounN . /
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�r Supplier Address
9cal Contra or / Compam ame
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ig Address (Contractor, Company or Owner Perfo ' g
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� gnature (Contrador omp ny r er Perfoi
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,� Contractor License Number
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Inst�llation)
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ning Installation) Phone
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BOMD OF ELEC7RICITY COPY
License Number
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ON BACK OF YELLOW COPY